Nurses, Case Managers Describe Life on the Front Lines of COVID-19
By Melinda Young
Case managers and other nurses are coping with changes in operations, home life, and job descriptions during the COVID-19 pandemic.
One of the more striking changes for case managers is the physical separation between them, their patients, and patients’ families.
“No visitors are allowed, so case management has to be done telephonically,” said Mary McLaughlin Davis, DNP, ACNS-BC, NEA-BC, CCM, senior director, care management nursing at Cleveland Clinic. “We even call our patients because we are not going into their rooms. It’s a work in progress.”
Building rapport with patients over the phone is challenging, she noted. “It’s a whole new way for acute care case managers to do their work, and we’re trying to navigate that change. Our social work colleagues already know the motivational interviewing techniques and questioning, and we’ve been teaching that for the past five years to everyone. It’s more important now than ever.”
But it is difficult for case managers to help patients without seeing the whole picture. For example, case managers often have developed nonverbal assessment skills and can read the patient’s body language, Davis said.
“We probably relied on that more than we knew, and now we don’t have it,” she added. “It would be interesting to see how case managers meet those obstacles, because our teams are very used to talking to a family directly, talking with patients directly, and even talking with doctors and nurses directly.”
Case managers also are dealing with transition challenges. Some skilled nursing facilities (SNFs) have stopped taking patients with COVID-19 because they do not have the resources. The California Association of Long Term Care Medicine issued a resolution on March 19, stating that hospitals should not force SNFs to accept new admissions of patients with clinical evidence or a positive test for the virus. (The resolution is available at: https://www.caltcm.org/assets/CALTCM%20COVID-19%20Resolution%20March%2019%202020.pdf.)
“I work with case managers on a daily basis, and they have a huge role in all of this,” says Alexander Wolf, DNP, RN, APRN, palliative care nurse practitioner at TriHealth in Cincinnati.
“Case managers are unsung heroes,” said Garrett P. Salmon, DNP, RN, APN, CRNA, assistant professor at Middle Tennessee State University. “Case managers work wonders for patients. I have friends who are case managers, and they work their tails off. Giving patients support is just as important as the healthcare they receive while they’re in the hospital.”
The case management role is evolving during the crisis, and case managers will need to call on every hard and soft skill they possess to get through it.
“I think this is a fluid, chaotic situation,” Wolf said. “We’re seeing the requirements from nursing homes changing by the day, sometimes.”
The American Health Care Association and the National Center for Assisted Living issued a joint guidance on long-term care (LTC) facilities accepting hospital discharges. The guidance states that SNFs should assume a person who appears asymptomatic has COVID-19 unless there is a negative test before admission. “We strongly urge LTC facilities to begin now creating separate wings, units, or floors by moving current residents to handle admissions from the hospital and keep current residents separate, if possible,” according to the guidance. (For more information, visit: https://www.ahcancal.org/facility_operations/disaster_planning/Documents/SNF-Admit-Transfer-COVID19.pdf.)
Some SNFs are requiring two negative tests. In many communities, the demand for rehab centers and nursing homes is extremely high, Wolf noted.
“I think we’re going to see a lot of patients, who, normally — in absence of COVID-19 — would go to these facilities, will end up going home,” he predicted. “It will create a huge burden on family caregivers, and it will fall on case managers to identify family members and community resources to support these patients.”
Ohio hospitals were seeing a surge of COVID-19 patients in early April, but not at the levels that overwhelmed hospitals in Michigan, New York, and Louisiana.
“We are not experiencing the extreme situation like New York and Italy,” Wolf said. “I’ve taken care of a number of COVID-19 patients now, but we haven’t had to ration out ventilators.”
Although Ohio’s situation looked more promising, perhaps because of the governor’s early decision to issue a stay-at-home order, hospital discharges remain a challenge because of the uncertainty and changing rules, he noted.
“Uncertainty is something I’ve been preparing families for when I talk with them,” Wolf added. “I provide a lot of education and am trying to get a strong sense of their home [resources].”
Case managers should look at patients’ support systems and think about what will happen if the non-COVID-19 patient is sent home and then becomes sick, or if the caregiver becomes infected with the virus. How will family members care for the patient if they have to practice social distancing?
“It’s a chaotic, uncertain time, and all of us are trying to stay informed, day by day, hour by hour,” Wolf added. “I think case managers are definitely going to be considered heroes at the end of this because they’ll be in the spotlight.”
Case managers also are dealing with changing roles and serving on the frontlines of the pandemic.
“We have literally built two new hospitals on our campus to accommodate the [expected] surge, and the case managers — along with every other nurse, physician, and therapist — are being upskilled to do bedside care, if necessary,” Davis says.
The new facilities, available to handle a surge of COVID-19 patients, were created from an existing hotel on the campus and a dentistry school.
Providers take a half-day of training from nurse educators. “Hands-on trainers are deployed, as well as the schools of nursing in the area have partnered with us to provide this massive education effort,” Davis explained. “Some retired nurses and physicians also have come forward to help.”
From the perspective of a long-time nurse case manager, switching to bedside nursing care is a major change from their professional life.
“The majority of us have been away from this for a long time,” Davis said. “Inserting catheters is not case management work, but nursing work, and I can do that. Then, if it goes on a long time, you will start to get a comfort level with other skills.”
When Davis shadowed a nurse on the floor, she still relied on her case management skills. “I could identify discharge concerns for certain patients, and I said, ‘This one will need this, and that one will need that. And, who is going to change your dressings at home?’”
Case managers who return to bedside nursing likely will find themselves filling both roles.
“I can see us putting on that case management hat if we are deployed to the bedside,” Davis said. “We’ll assist in that way, too.”
Case managers and other nurses are coping with changes in operations, home life, and job descriptions during the COVID-19 pandemic. One of the more striking changes for case managers is the physical separation between them, their patients, and patients’ families.
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